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For young people

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Psychotic Disorder Assessment & Treatment

About

Schizophrenia spectrum and other psychotic disorders are made up of disorders that include schizophrenia, other psychotic disorders, and schizotypal personality disorder. Schizophrenia spectrum diagnoses make up about two-thirds of all psychotic disorders.

People with psychotic disorders experience changes in the way they interpret reality. Every individual is different and symptoms of psychosis can vary from person to person, and can also change over time. Some common symptoms of psychotic disorders are:

Hallucinations: having the sense of experiencing something that really isn't there (e.g., seeing, hearing, smelling, tasting or feeling things that do not exist in reality but is experienced by the person as extremely real)

Cognitive changes:

Delusional thinking or false beliefs, having fixed thoughts about something that probably isn't true and not accepting any logical arguments that it isn't the case (e.g., believing that your thoughts are being controlled by an external force)

Difficulty concentrating, paying attention and remembering things

Everyday thoughts can seem confusing or jumbled, and thoughts might seem faster or slower than usual

Behavioural changes:

Social isolation or becoming withdrawn

Problems with work, social or family life

Problems with motivation or problems with increased activity

Laughing at inappropriate times or becoming upset without an identifiable cause

Physical changes:

Problems with sleep (e.g. not sleeping due to preoccupation with thoughts)

Onset, prevalence, and burden of psychotic disorders in young people

Around 3 in every 100 people in the general population will experience a psychotic disorder at some stage in their lives (1). The lifetime prevalence of schizophrenia disorder is just under 1 in every 100 people (1). At 21%, schizophrenia is the leading principal diagnosis of young people in contact with community mental health services in Australia (2). It is also the third leading contributor to the burden of disease and injury in Australian males aged 15-24, and the fifth leading contributor for females of the same age (3).

Psychotic disorders are rare before the age of 14 years, but there is a sharp increase in its prevalence between the ages of 15-17 years (4). Overall, about 50% of people who develop a psychotic disorder will do so by the time they are in their early 20s. The mean age of onset tends to be a little younger in males (18-25 years) than females (25-35 years) (4,5).

Risk factors

A number of factors are known to increase the likelihood that a person will have a psychotic disorder (6-8) They include:

Early life factors:

Genetic vulnerability - family history of psychotic disorder

Complications during pregnancy or birth (e.g. fetal hypoxia)

Season of birth (late winter/early spring)

Developmental delay

Traumatic experiences (e.g. abuse or neglect)

Late childhood/adolescent factors:

Substance use, particularly cannabis

Psychosocial stress

Urbanicity

Migration

Cognitive impairments

'Attenuated' or mild psychotic symptoms

It is important to note that psychotic symptoms seem to be part of the continuum of normal experiences. In the general population, there is a median prevalence rate of approximately 5% and a median incidence rate of approximately 3%, and 75-90% of psychotic experiences are transitory and disappear with time (9). Therefore, the presence of psychotic symptoms does not automatically indicate a diagnosis of a psychotic disorder, and a comprehensive assessment over time is necessary.

Assessment

Formal systems for the diagnosis of mental illness (1,2) describe a number of different types of psychotic disorder, including:

Schizophrenia (psychotic illness has been continuing for at least 6 months, with at least 1 month where symptoms were active)

Schizophreniform disorder (psychotic illness has been continuing for less than 6 months)

Schizoaffective disorder (co-occurring symptoms of psychosis and a mood disorder, such as depression or bipolar disorder, and were preceded or are followed by at least 2 weeks of delusions or hallucinations without prominent mood symptoms)

Delusional disorder (having at least one month of delusions but no other psychotic symptoms)

Brief (or acute or transient) psychotic disorder (psychotic symptoms develop suddenly in response to major stress - lasts more than 1 day and remits by 1 month)

Schizotypal personality disorder

Assessment Tools

To decide whether a young person may be experiencing a psychotic disorder, a comprehensive, longitudinal assessment by a mental health professional is required. It is important to note that assessment must be an ongoing process and aside from gaining information about symptoms, the purpose of assessment also includes engaging the young person in order to develop a therapeutic alliance and seeking to understand the personal context of their symptoms (3).

Providing a thorough assessment should be balanced with the need to develop a therapeutic alliance with the young person, and techniques to promote engagement should be incorporated into the assessment (3). This could include interviewing techniques such as careful listening, taking the young person and their concerns seriously, providing an optimistic, calm, and supportive environment, ensuring there is sufficient time for the interview, and using open-ended questions as far as possible (4).

As a first step, the assessment should cover the following domains (3,4):

Clinical and personal history, including the context for their current symptoms

Mental state examination (in particular, the young person's insight)

Biological assessment (e.g. comorbid medical conditions)

Cognitive assessment, including social cognition

Comorbid psychiatric disorders, including substance misuse

Risk assessment (risk of harm to self or others, risk of neglect or victimisation, and risk of non-adherence to treatment or disengagement from services)

It may also be beneficial to use a standardized assessment interview such as the Comprehensive Assessment of At-Risk Mental States (CAARMS) (5) to assist in assessing symptoms that may indicate imminent development of a psychotic disorder and to determine if a young person meets criteria for being at ultra high risk for onset of a psychotic disorder.

Treatment

Early detection and treatment of psychotic disorders is important for reducing the distress associated with psychotic symptoms and helping the affected person to retain their day-to-day functioning (eg. at school or work, and their relationships with family and friends). There is considerable interest in the potential to prevent the onset of psychosis and to use early, intensive treatment to reduce its short-term damaging effects (such as loss of work or social functioning) and improve long-term recovery.

Different stages of illness (e.g. ultra high risk, first-episode psychosis) and different phases of acuity (e.g. acute, recovery, or relapse) might indicate different treatment approaches. The current Australian clinical guidelines for the treatment of psychosis provide recommendations according to stages of illness and acuity (1).

Integrated early intervention services for a first episode of psychosis (FEP) have been developed in Australia and elsewhere, and have been found to have clinically significant benefits over standard care (2). Common components of an integrated early intervention FEP service include:

A longer duration of untreated psychosis before diagnosis and treatment can worsen the medium- and long-term outcomes (5). Effective intervention in the early stages of illness can help reduce long-term disability in work and family, education, and social relationships.

In areas where such integrated early intervention specialised services do not exist, general practitioners may need to initiate early treatment and provide ongoing clinical management (see (6) for a summary of key issues for acute management).

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headspace would like to acknowledge Aboriginal and Torres Strait Islander peoples as Australia’s First People and Traditional Custodians. We value their cultures, identities, and continuing connection to country, waters, kin and community. We pay our respects to Elders past and present and are committed to making a positive contribution to the wellbeing of Aboriginal and Torres Strait Islander young people, by providing services that are welcoming, safe, culturally appropriate and inclusive.

headspace is committed to embracing diversity and eliminating all forms of discrimination in the provision of health services. headspace welcomes all people irrespective of ethnicity, lifestyle choice, faith, sexual orientation and gender identity.

headspace centres and services operate across Australia, in metro, regional and rural areas, supporting young Australians and their families to be mentally healthy and engaged in their communities.

headspace National Youth Mental Health Foundation is funded by the Australian Government Department of Health. headspace National Youth Mental Health Foundation Ltd is a health promotion charity that has been endorsed as a deductible gift recipient. ABN 26 137 533 843